Veterans Affairs Committee on Nov. 16th, 2010

[The Chair, Conservative, Gary Schellenberger]

Welcome, everyone, to meeting number 28 of the Standing Committee on Veterans Affairs.

Pursuant to Standing Order 108(2), we are studying combat stress and its consequences on the mental health of veterans and their families.

Today as our witnesses we have, from the Department of Veterans Affairs, Janice Burke, director of mental health; Raymond Lalonde, director, National Centre for Operational Stress Injuries, Ste. Anne’s Hospital; and Tina Pranger, national mental health officer. Welcome.

Janice, if you’re going to lead the proceedings off, please go ahead.

[Janice Burke, Director, Mental Health, Department of Veterans Affairs]

Thank you very much, Mr. Chair and committee members.

As the chair indicated, my name is Janice Burke and I am the director of mental health for the Department of Veterans Affairs. With me to also respond to questions is Raymond Lalonde, director of the National Centre for Operational Stress Injuries, and Dr. Tina Pranger, who is our national mental health officer for the Department of Veterans Affairs.

We are very pleased to be here today to talk to you and provide you with information on what the Department of Veterans Affairs is doing in the area of mental health and how we're responding to the needs of veterans and their families who have been exposed to trauma or operational stress injuries in the military, and how we are supporting them in their re-establishment and transition to civilian life and to their communities.

The presentation deck in your package has more details, certainly, than what I will cover, but we hope it provides you with information to assist you with your study regarding combat stress and its impact and effects on the mental health of veterans and their families.

Operational stress injury, for folks who may be new to the committee and may not be aware, is a term used by National Defence, Veterans Affairs, and the RCMP. It's defined as a persistent psychological difficulty resulting from operational stress in duties performed while serving in the Canadian Forces or in the RCMP. I need to point out that it is not a medical diagnosis; it's just a term to describe a broad range of medical diagnoses such as anxiety, depression, and post-traumatic stress disorder.

Response to operational and combat stress has been described also in different diagnostic terms over the years, from the American Civil War to World War I and World War II. It's been stated as things like soldier's heart, battle fatigue, shell shock, and psycho-neurosis. So the name has evolved to being recognized, in 1980, as post-traumatic stress disorder in the diagnostic and statistical mental disorders.

The type of trauma that can result in a significant stress reaction can range from threat of death or threat of serious injury, to the viewing or handling of bodies and the witnessing of human degradation. Reactions to such stress, I must point out, are normal, and with early intervention, education, counselling, and treatment, we believe that the impact of trauma on veterans and their families can be reduced significantly.

The development of severe post-traumatic stress disorder and other mental health conditions we believe can also be prevented, or at least the symptoms reduced significantly.

An operational stress injury without proper and early intervention and treatment can lead to things like, and not in all cases, absenteeism from work, unemployment, family relationship problems, alcohol and drug use, social isolation, involvement with the criminal justice system, homelessness, and risk of suicide.

As in the case of the general Canadian population, stigma remains a major impediment to achieving early intervention and preventing mental illness or preventing the severe impacts of post-traumatic stress disorder.

I have to point out that there has been considerable work by the Department of National Defence around reducing stigma and educating about operational stress injuries through the education that's provided by their speakers bureau network and other anti-stigma campaigns they've had under way.

The establishment of the VAC/DND operational stress injury and social support program, which is also known as OSISS, and the joint network of over 15 operational stress injury clinics has allowed us to ensure early referral, diagnosis, assessment, treatment, and psycho-social education. And this has helped, we believe, to reduce stigma, achieve early intervention, and improve treatment outcomes.

Pre- and post-deployment education and screening of Canadian Forces members and appropriate timely referral to counselling and other services are also making a difference. For example, we know that approximately 53% of our VAC clients who have service in Afghanistan and who have a service-related disability are currently still serving in the military. So we have 1,504 clients with Afghanistan service who have a disability benefit relating to a psychiatric condition, and of those, 797 are still serving.

To support veterans with mental health conditions and their families in their journey to recovery and to ensure their successful transition and re-establishment to civilian life, Veterans Affairs has put in place several important measures. I'm not going to go into the details. We may cover it throughout the session, but you'll see that they're listed in your deck in slides 17 to 21. Also listed in the deck, from slides 22 to 23, are initiatives that are in process of being implemented but are not yet completed.

These initiatives, I have to point out, are built around the Department of Veterans Affairs mental health strategy framework. Our framework focuses on ensuring that a continuum of programs and services are in place to fully meet the needs of veterans and their families. These areas include economic, social, health, and physical environment supports. These supports can be provided either through Department of Veterans Affairs programs or through community, provincial, and non-government organizations.

Our strategy, therefore, also includes enhancing awareness of the needs of veterans and their families in the communities where they live; building sufficient capacity in our programs and in provincial and community programs to effectively treat veterans and their families; and ensuring that there are no gaps.

Partnerships in the area of mental health are therefore extremely important to veterans and their families, and to the Department of Veterans Affairs. You will see from the deck that we are putting an unprecedented focus on not only strengthening current partnerships with National Defence and veterans organizations, such as the Royal Canadian Legion, but also on nurturing new partnerships that will improve programming, services, and supports to veterans and their families in the communities where they live.

It is important to emphasize, as well, that while all of the initiatives listed in the deck contribute to improving transitioning and the re-establishment to civilian life for our veterans and their families, the implementation of the new Veterans Charter--with its focus on recovery, wellness, and independence--has been, and will continue to be, of paramount importance to the recovery of veterans with mental health conditions and their families.

The new Veterans Charter is also enabling Veterans Affairs staff to provide more holistic case management to veterans and their families who are struggling with their mental health, and to treat all barriers including medical, psycho-social, and vocational that are affecting their re-establishment. The new Veterans Charter does not limit supports to the medical treatment of a veteran's pensioned condition, as was the case prior to the implementation.

I would like to acknowledge and emphasize the importance of family in the veteran's recovery process, and highlight that military trauma has significant impact not only on the veteran but also on his or her family. In recognition of this, Veterans Affairs has improved supports to families, beginning with the implementation of the new Veterans Charter. Families are now part of the veteran's rehabilitation and case management plan, and they receive treatment, counselling, and support if needed from the operational stress injury clinics.

The clinics have recently developed, in partnership with community organizations, two unique psycho-education programs for children affected by operational stress injury. The first is a ten-week program for children ages eight to twelve who live with a parent affected by an OSI, and the second is a six-session program for youth ages twelve to sixteen.

With the new Veterans Charter, the veteran's spouse can receive vocational assistance if the veteran, because of his or her mental health condition, is not able to participate in rehabilitation or employment due to his or her disability or death. Income support for the family is also guaranteed if the disability is such that the veteran cannot be gainfully and suitably employed.

In addition, more resources have been added to our OSISS program--and that's the peer support program I mentioned earlier--to provide more peer support to families and to strengthen our volunteer network.

I'm not sure if you're aware, but we have a volunteer network of peer support people across the country who volunteer their time to provide support to families, to peers, and also to those who are in the bereavement process.

Veterans Affairs is also forging partnerships with national, provincial, community, and non-government organizations to raise the awareness of veterans with mental health conditions and their families, and to improve access, coordination, and delivery of required supports in the communities where they live.

As a final remark, I want to mention that suicide prevention is a priority for Veterans Affairs. I know your committee has a special concern in this regard. We recognize, as you do, that one of the most devastating and tragic consequences of serious mental, physical, social, and emotional problems occurs when someone takes his or her own life.

Although we do not know the rate of suicide in the veteran population or in our VAC client population--the rate of suicide we hope will be obtained through data, through work with Statistics Canada and National Defence, and we’ll have that in early 2011--we do know that even one death by suicide is too many.

Veterans Affairs also provided training to all staff in the area of suicide prevention in 2009. That’s all front-line staff. We have suicide protocols in place for use by all staff who work with veterans and their families.

In addition, in 2010 we undertook a review of our approaches to suicide prevention, and as a result we are now implementing several recommendations to strengthen suicide prevention within Veterans Affairs Canada.

We actually have Dr. Tina Pranger here with us today. She is the author, with folks from our research directorate, of those two reports and the recommendations. If there is interest, even at a later time, we would be pleased to go through that in detail with you.

This concludes my opening remarks. Thank you for the opportunity to appear before you. We look forward to responding to any questions you may have.

[The Chair, Conservative, Gary Schellenberger]

Thank you.

The first question will be from Ms. Duncan. You have seven minutes.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

Thank you, Mr. Chair.

Thank you to the witnesses for coming.

I am going to begin by making a few comments about concerns I have.

I really think we need to focus on the epidemiology, the extent of the problem. What are the causal factors? What are the warning symptoms for families? Prevention has to be our goal.

In stating that, there is currently no mechanism in place to say how many Canadian Forces personnel or veterans have been treated for an operational stress injury, anxiety, depression, or PTSD or how many have needed in-patient care. That national database is critical for understanding the extent of the problem. It would allow us to evaluate various clinical interventions, and it could be used to target education and training initiatives.

I’m also concerned that the automated medical record-keeping system, which was to be operational in 2008, was delayed until 2011 and is now delayed until March 2012.

Another concern is the mental health survey, which won’t be undertaken until 2012. Some of these recommendations go back to 2002.

I’m going to focus on treatment. There is considerable variation across the country. If we look at the five regional mental health centres, there are delays of up to four weeks for treatment. In the last week alone, I have had ten requests, from very desperate people, for psychiatrists. I was on the phone last night until midnight with two of those people. Is four weeks okay when you have people suffering from PTSD and worse?

[Janice Burke]

I can begin. Thank you for your question.

I’ll try to go in order, based on what your first questions were.

You mentioned your concern about the epidemiology and the causative factors. In terms of the research we have on PTSD, at least, it has been pretty well identified in terms of the cause. I agree with you in terms of prevention or at least minimization of symptoms. It is extremely important. That’s what makes PTSD so complicated.

Our Canadian Forces, by virtue of the kind of work they do and the kinds of deployments they are undertaking, are exposed to trauma. It’s part of their functions and duties. That’s why the work the Canadian Forces is doing in terms of pre-deployment screening and pre-deployment education and post-deployment screening when they come back post-deployment, which occurs either at the three-month period or at the six-month period to pick up on signs in terms of reducing the impact of the trauma, is so important.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

Sorry, I’m going to interrupt. The answer I’m looking for is we’re waiting.... Some of our people are waiting up to a month for treatment. Is that okay?

[Janice Burke]

No.

When we look at wait times for treatment.... As you know, Veterans Affairs Canada does not actually provide health care to veterans. However, we do purchase and we do have our operational stress injury clinics that can provide immediate access to veterans who are in need of that access.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

They get immediate access.

[Janice Burke]

Yes.

Raymond, I think you can respond in terms of even our turnaround times for people to get into the clinics.

[Raymond Lalonde, Director, National Centre for Operational Stress Injuries, Ste. Anne's Hospital, Department of Veterans Affairs]

Maybe for clarification, when you were talking about five centres across the country with wait times, you’re probably talking about the Canadian Forces operational trauma clinics.

At Veterans Affairs, we have nine outpatient clinics across the country. We have over 2,000 service providers. All Veterans Affairs veteran clients have access, if it is urgent, to any public service medical attention, emergency psychiatric services; they’re all available to veterans. They can go in. If there is an urgent need, they can go to any hospital or resource centre in their community to get help. As far as Veterans Affairs, they can be referred to private providers. In most of the country, we have very good coverage with the 2,000 service providers.

We have to remember that we have over 13,000 clients with mental conditions. Having 2,000 service providers registered with the department to provide services is a very large number. In our OSI clinics, once we receive a referral from the district office, we can see the clients based on need. Normally, our turnaround time for the initial visit is 15 working days, but if there is an emergency, the client can go to the public services. To come to the clinic, we say 15 days, but once we have a contact, we are in charge of the clients and we assess the level of need. Depending on the situation of the client, he could be seen in a week, he could be seen in a month. It depends. He is taken in charge by the clinic.

[Kirsty Duncan, Liberal, Etobicoke North, ON]

My understanding is it's 15 days to get the appointment, and then 15 days is the hope for treatment.

As one young man said to me.... I don't even want to use his words, they're so awful. He said those wait times don’t mean anything when you’ve got both barrels of a shotgun....

[Janice Burke]

Absolutely. In those situations, in our VAC office, a case manager is generally assigned to veterans, particularly veterans who have more severe PTSD and require rehabilitation. It starts with the case manager who is working with the veteran, and if it is identified, obviously, that the veteran is either suicidal or there are major issues where they require treatment--

[Kirsty Duncan, Liberal, Etobicoke North, ON]

As long as they know about them.

[Janice Burke]

Yes, that’s the key. But if I could add as well, when we have people within 72 hours.... For example, because we have agreements with seven treatment centres that treat PTSD, co-morbid conditions, PTSD and substance abuse, we have been able to get people into these centres. We have seven of them across the country. As you pointed out, the importance is our awareness of the individuals and ensuring that they get the support of--

[The Chair, Conservative, Gary Schellenberger]

Okay. You will have to do it in the next round.

[Janice Burke]

Mr. Vincent.

[Robert Vincent, Bloc, Shefford, QC]

Thank you, Mr. Chairman.

Have you read the Report of the Canadian Forces Expert Panel on Suicide Prevention, which was prepared in 2007? You say you want to know the number of suicides in the armed forces. You'll find the data for the period from 1995 to 2008 on page 9.

That same report also states: "Expansion of the CF's mental health staff will shortly result in Regular Force members having approximately twice as many mental health providers per capita relative to Canadian civilians."

How many new mental health professionals have you hired since 2007?

[Raymond Lalonde]

Your comment concerns the Canadian Forces, not us. The distinction has to be made between the Canadian Forces and us; we are the Department of Veterans Affairs.

The Canadian Forces were normally supposed to double their strength, which they did or are about to do.

As for us, since 2007, we have doubled the number of clinics specialized in the treatment of post-traumatic stress. We now have nine out-patient clinics, in addition to a residential clinic. So we've doubled capacity. We also have 2,000 service providers. As we said earlier, we have agreements with clinics which have residential programs, private hospitalization programs, where PTSD and substance abuse problems can be treated. Our seven clinics really respond to the demand of our clientele.

[Robert Vincent, Bloc, Shefford, QC]

How many of the individuals you have treated for post-traumatic stress problems have committed suicide? Do you have any figures to provide us?

[Raymond Lalonde]

As we told you earlier, there will be a study—

[Robert Vincent, Bloc, Shefford, QC]

At your hospital, clinicians treat patients, but you don't know whether any of them have committed suicide. Is that what you're telling me?

[Raymond Lalonde]

It's provincial clinics that we fund.

[Robert Vincent, Bloc, Shefford, QC]

I visited your hospital. I saw people suffering from post-traumatic stress disorder on the third floor. So there are people dealing with this problem who are recovering at your facilities with a view to returning to society. Have any people who have come to you for specific post-traumatic stress care committed suicide?

[Raymond Lalonde]

There are definitely some people who have been seen in our clinics at one place or another across the country who have committed suicide.

[Robert Vincent, Bloc, Shefford, QC]

But with regard to your institution, you don't know.